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On 10/6/2015, a patient presented to the emergency department with pain in the back of his neck, ongoing headache, and intermittent fever over the past two weeks.  The patient had a recent history of visual and auditory hallucinations.  The patient was also receiving interferon therapy.

The patient was febrile, tachycardic, and had classic findings of meningitis.  The ED physician ordered for the patient to undergo a lumbar puncture for collection of cerebrospinal fluid (CSF) to confirm or exclude conditions, including meningitis or a subarachnoid hemorrhage.  The patient’s CSF indicated an elevated white blood cell count with zero organisms detected.  The ED physician attributed these results and symptoms to viral meningitis.  The CSF results noted that the fluid was cloudy and had xanthochromia, but these findings were not acknowledged by the ED physician.

The ED physician did not rule out the possibility of a head bleed or bacterial meningitis and did not administer antibiotics prior to discharging the patient home after also obtaining blood cultures.  The patient was immunocompromised by interferon therapy with pancytopenia, which can cause atypical responses to infections.  Xanthochromia and cloudiness of the CSF could be caused by bacterial meningitis.

The blood cultures came back positive for Staphylococcus aureus infection within twenty-four hours.  The patient was called back to the hospital and admitted for treatment.  Subsequently, the patient was diagnosed with a cervical spine epidural abscess and suffered permanent neurologic impairment.

The Commission stipulated the ED physician reimburse costs to the Commission, complete 6 hours of continuing education on the analysis of cerebrospinal fluid, implications of xanthochromia, and the differential diagnosis of meningitis in patients with headaches, and write and submit a paper of at least 1000 words, plus bibliography, addressing the analysis of cerebrospinal fluid, implications of xanthochromia, and the differential diagnosis of meningitis in patients with headaches.

State: Washington

Date: May 2016

Specialty: Emergency Medicine, Internal Medicine

Symptom: Fever, Headache, Head/Neck Pain

Diagnosis: Meningitis/Encephalitis

Medical Error: Diagnostic error

Significant Outcome: Permanent Loss Of Functional Status Or Organ, Hospital Bounce Back

Case Rating: 5

Link to Original Case File: Download PDF

On 1/25/2015, a patient, previously a retired nurse, presented to the emergency department (ED) with cough, headache, fever, muscle pain, nausea, and neck pain after three days of increasing symptoms.  The patient disclosed a medical history including surgery for an acoustic neuroma about two years prior and stated that her neck pain may be related to recent heavy lifting.  The patient was examined by a physician who noted no meningismus and diagnosed an influenza-like illness.  The patient was discharged with medications for nausea and migraine headache, and was directed to return to the ED if there were new or worsening symptoms.

On 1/26/2015, the patient was treated by an ED physician when she returned to the ED with complaints of uncontrolled neck pain and nausea.  The patient’s headache and back pain were improved by IV pain medication while treated in the ED, but not her neck pain.  The ED physician ordered an MRI study of the patient’s cervical spine based on the patient’s highly elevated white blood cell count and concerns of a possible bacterial infection.  The radiology report noted an abnormality that could have been produced by meningitis or prior lumbar puncture, and recommended that a lumbar puncture be performed.

Later that morning, the ED physician discussed the imaging findings with the patient.  The patient disclosed that she had a previous lumbar puncture and the ED physician sensed that the patient did not want to undergo another lumbar puncture procedure, unless necessary.  The ED physician and patient discussed various medical factors, including the patient’s improved condition and lack of other symptoms indicating meningitis.  The ED physician decided not to order an LP and discharged the patient with medication for nausea and pain with instructions to return if her condition worsened.  The patient returned to the ED later that evening and presented with increased confusion.

The patient had a seizure, became comatose, and lost brainstem reflexes.  The patient was examined by a neurologist who confirmed brain death.  The patient was taken off life support and expired.  An autopsy was performed and concluded that the cause of death was acute bacterial meningitis.

The Commission stipulated that the ED physician reimburse costs to the Commission, make a presentation regarding the diagnosis and management of meningitis (with specific reference to this case) to other physicians and physician assistants at her group practice, complete 4 hours of continuing education on the diagnosis and management of meningitis, and write and submit a paper of at least 1000 words, plus bibliography, addressing the diagnosis and management of meningitis.

State: Washington

Date: February 2016

Specialty: Emergency Medicine

Symptom: Fever, Confusion, Cough, Headache, Head/Neck Pain

Diagnosis: Meningitis/Encephalitis

Medical Error: Diagnostic error, Physician concern overridden

Significant Outcome: Death, Hospital Bounce Back

Case Rating: 5

Link to Original Case File: Download PDF

In November 2009, California was near a second peak of the bimodal H1N1 influenza pandemic that began in Mexico in April 2009.  Rapid flu testing at this time was of limited value in detecting H1N1.  Healthcare facilities were inundated with patients complaining of influenza-like illnesses.

On 11/2/2009, a 23-year-old female with a history of current smoking, mild asthma, and allergic rhinitis was seen by a physician assistant at an urgent care clinic where a family practitioner worked.  She presented with headache, nausea, fatigue, and body aches for days.  She was afebrile and had no skin rash.  Rapid flu A&B testing was negative.  The patient was diagnosed with a viral syndrome and treated with fluids and rest.

On 11/16/2009, the patient returned to the urgent care clinic for a chief complaint of bug bites on her legs.  She was seen by the family practitioner.  She no longer complained of flu-like symptoms.  Insect bites were noted to have been present for one week.  The family practitioner documented that she was afebrile and had multiple maculopapules and pustules on the left lower extremity.

The family practitioner did not obtain a skin culture.  He diagnosed the patient with cellulitis of the leg and insect bites.  The family practitioner failed to document in the patient’s medical record the basis for his diagnosis of cellulitis.  The family practitioner started the patient on Bactrim DS twice daily for 10 days.

The patient was evaluated by a dermatologist on 11/17/2009 for multiple insect bites with swelling and itching.  She did not complain to the dermatologist of fever, chills, weakness, or muscle aches.  She was instructed to take Bactrim DS as prescribed by the family practitioner and was given Altabax and Lidex cream for topical wound care.

The patient returned to urgent care on 11/22/2009.  She was seen by a different physician with fever to 104, cough, malaise, body aches, and bug bites.  The patient had stopped taking Bactrim due to nausea but then resumed taking it after seeing the dermatologist.

On exam, an elevated temperature of 100.2 and tachycardia at 114 were noted, as were congested nares, red throat, and swollen neck lymph nodes.  The rash on the left lower extremity persisted, so a scab was removed from one of the lesions for a culture.  The culture result was negative when reported on 11/23/2009.  Rapid flu testing was also negative.  The treating physician suspected flu and prescribed Tamiflu, 75mg per day, and Phenergan for nausea.  The patient was continued on other treatments, per the dermatologist’s orders, for left lower extremity rash.

On 11/22/2009, the patient’s mother telephoned the urgent care clinic and reported that the patient had a rash all over her back.  A physician assistant advised the patient to stop Tamiflu and to replace Bactrim with Omnicef.  The patient’s mother was advised to return to the clinic or to go to the emergency department if the patient’s condition worsened.  On the morning of 11/23/2009, the patient’s mother telephoned the clinic again, reporting that the patient had a fever and was nauseated.  She was advised to bring the patient to the clinic.

On 11/23/2009, the family practitioner saw the patient with her mother present.  The patient presented with a history of continued fever, chills, cough, nausea, and vomiting.  The family practitioner was aware that the patient was told to stop using Tamiflu and that her Bactrim prescription was replaced with Omnicef.  The family practitioner did not perform and/or document a skin examination, even though one of the patient’s complaints was that she had a new rash.  On exam, the patient had a fever with a temperature at 101.2, tachycardia with heart rate at 118, and a normal blood pressure.

The family practitioner charted that she was “ill appearing but in no acute distress.”  HEENT, heart, lung and abdominal exams were negative.  The family practitioner’s assessment was “fever not otherwise specified, URI, and nausea with vomiting.”  The family practitioner’s medical record does not support a diagnosis of URI, as the only recorded symptom consistent with that diagnosis is a cough.  Other symptoms of URI, such as red throat, enlarged lymph nodes, and nasal congestion, which were documented by another doctor on 11/22/2009, were absent from the record of the patient’s visit on 11/23/2009.  The family practitioner later stated that on 11/23/2009, he was primarily concerned about the patient’s dehydration, though he failed to document this concern in the patient’s chart.  He ordered an intramuscular injection of Reglan 10 mg for nausea.  His plan was to continue with Onmicef for the URI, even though this medication was originally prescribed for a skin rash.

The family practitioner’s follow-up plan, in its entirety, is documented as follows: “ER worse.”  The family practitioner later claimed that this annotation meant that he wanted the patient to be referred to the emergency department and that he discussed this issue at length with the patient’s mother who declined this because of cost.

However, the family practitioner failed to document this discussion in the patient’s chart.  The family practitioner decided to continue treating the patient on an outpatient basis instead of hospitalizing her or referring her to the emergency department.  Despite the fact that this patient had developed a new rash, continued to have fevers and cough for a week, and continued to have two days of vomiting to the point where she could not keep medications down, the family practitioner failed to order laboratory or imaging studies and did not formulate or document a sufficiently detailed treatment plan.

In the early evening of 11/23/2009, the patient was unarousable at home and was taken to the hospital by paramedics.  Upon arrival at the hospital, she suffered generalized tonic-clonic seizures, which continued despite medication.  Despite aggressive treatment in the emergency department, her condition did not improve, and she was admitted to the intensive care unit, where she received consultations from multiple specialists.

On 11/24/2009, after the family practitioner found out that the patient was admitted to the intensive care unit, he made an addendum to the patient’s chart regarding the 11/23/2009 visit. The information added to the patient’s chart was a report of a neurologic examination.  In this addendum, the family practitioner charted that the patient was alert and oriented X3 with normal cognition, cranial nerves II-XII grossly intact, normal strength bilaterally, and normal gait.  At least a portion of this neurologic examination did not actually take place.

The patient was examined on 11/23/2009, with her mother present, and she claimed, and the family practitioner later admitted, that he did not perform a cranial nerve examination or motor strength bilaterally.  The remaining portions of the added neurological examination note were based on the family practitioner’s recollected observation of the patient on 11/23/2009 and were not a result of a purposeful neurological examination, as his note made it appear.

On 11/26/2009, after a second neurological consultation, the patient was declared brain dead.  On the basis of a subsequent autopsy, the cause of death was determined to be Reyes syndrome and viral encephalitis.

The family practitioner departed from the standard of care in his treatment of the patient as follows:

1) The family practitioner’s inadequate history and physical examination, including a failure to perform a skin examination of the patient on 11/23/2009 was a simple departure from the standard of care.

2) The family practitioner’s failure to perform and/or document a neurological examination of the patient on 11/23/2009 was a simple departure from the standard of care.

3) After deciding to continue treating the patient on an outpatient basis, family practitioner’s failure to order any laboratory or imaging studies on 11/23/2009 was a simple departure from the standard of care.

4) The family practitioner’s failure to formulate a treatment plan that addressed the patient’s symptoms on 11/23/2009 was a simple departure from the standard of care.

5) The family practitioner’s 11/24/2009 recording of elements of the neurological examination of A.C. that he did not actually perform was a simple departure from the standard of care.

The Board judged the family practitioner’s conduct to have fallen below the standard of care.  Stipulations included enrolling in the Physician Assessment and Clinical Education Program offered at the University of California – San Diego School of Medicine.  The Board issued a public letter of reprimand.

State: California

Date: March 2014

Specialty: Family Medicine, Dermatology, Emergency Medicine, Infectious Disease, Internal Medicine

Symptom: Dermatological Abnormality, Cough, Rash, Fever, Headache, Nausea Or Vomiting

Diagnosis: Meningitis/Encephalitis

Medical Error: Failure to examine or evaluate patient properly, Failure to order appropriate diagnostic test, Ethics violation, Lack of proper documentation

Significant Outcome: Death

Case Rating: 5

Link to Original Case File: Download PDF

On 5/18/2009, a 5-week-old patient was seen by a pediatrician with symptoms of an upper respiratory infection.  The pediatrician advised the patient’s mother to use a humidifier, Vicks vapor rub, and a nasal bulb suction.

On 5/27/2009, the pediatrician saw the patient for cough, congestion, and a possible fever.  The pediatrician was informed that the patient had been exposed to sick siblings and that the patient had been given Xopenex, from a sibling’s prescription, prior to being seen by the pediatrician. The patient was noted to have low oxygen saturation, but no wheezing.  The pediatrician conducted an examination which was stated to be unremarkable, and he did not hear any wheezing. The pediatrician diagnosed the patient with cold symptoms, RSV bronchiolitis, ALTE, and hypoxemia.  The pediatrician prescribed Xopenex and Solu-Medrol.  He admitted the patient to the hospital. The pediatrician ordered laboratory tests which included the basic metabolic panel (CHEM 7), RSV swab, influenza swab, chest X-ray, and a complete blood count (CBC).

Later on 5/27/2009, the pediatrician was informed of the lab results verbally by the pediatric floor nurse.  The CHEM 7, RSV swab, and influenza swab were normal. The chest X-ray showed changes compatible with RSV Bronchiolitis.  The CBC showed a white blood count of 7.2 with 59% neutrophils and 25% bands. The pediatrician was not verbally informed of the band count on that date.  The lab results were also faxed to the pediatrician’s office and were received on 5/28/2009 at 7:54 a.m.

On 5/28/2009, the patient was reported to be lethargic, irritable, and inconsolable.  The patient also exhibited abnormal seizure-like movements and was given oxygen to keep the O2 saturation above 93%.  The pediatrician ordered EKG/EEG and upper gastrointestinal (UGI) exams and for the patient to be evaluated for gastroesophageal reflux disease (GERD).  The pediatrician also started the patient on Zantac. The patient experienced repeat episodes of bradycardia and cyanosis later that day.

On 5/29/2009, the patient continued to have apnea, with bradycardia and cyanosis, and increasing lethargy and irritability.  The patient was also reported to have a firm and bulging fontanelle with left eye deviation. The pediatrician ordered a blood culture, and upon receiving the results, ordered ampicillin and cefotaxime.  The patient continued to become increasingly irritable and lethargic, and had eye twitching and jittery movements. The Rapid Response Team was called twice to evaluate the patient. The pediatrician ordered Gavage feeding and Reglan.

On 5/30/2009, the patient was bagged and given a loading dose of phenobarbital.  He was noted to have photosensitivity, clenched fists, a bulging Fontanelle, and repetitive bicycling motions.  The dose of phenobarbital was increased, but the patient’s seizure-type episodes continued. The pediatrician performed a lumbar puncture and obtained a cloudy and yellow cerebrospinal fluid.  The pediatrician ordered an infectious disease consult, CBC, CRP, and MRI of the head. The patient was diagnosed with sepsis and meningitis. The patient was thereafter transferred to a different medical center.

The pediatrician committed gross negligence in his care and treatment of the patient, which included the following: the pediatrician failed to appropriately evaluate, diagnose, and treat the patient’s signs and symptoms of sepsis and meningitis; he prescribed Reglan and Gavage feeding when it was not appropriate based on the patient’s signs and symptoms; and he failed to consider the most likely cause of the patient’s presenting symptoms in making the decision for the treatment.

The Medical Board Of California ordered that the pediatrician be placed on probation for a period of three years, complete a medical record keeping course, and complete a clinical training or educational program equivalent to the Physician Assessment and Clinical Education Program (PACE).

State: California

Date: January 2014

Specialty: Pediatrics

Symptom: Cough, Fever

Diagnosis: Meningitis/Encephalitis, Sepsis

Medical Error: Failure to examine or evaluate patient properly, Improper medication management

Significant Outcome: N/A

Case Rating: 5

Link to Original Case File: Download PDF

In early 2002, a 34-year-old male was having difficulties with his ears and was referred to an otolaryngologist.  On 2/15/2002, the otolaryngologist took a history from the patient and performed a physical examination.  His findings and plan were the following:

1) The patient had a history of ear infections and in the past had tubes inserted.

2) The patient had been on antibiotics for 10 days.

3) The right ear had adequate retraction, pocket collapse, and possible cholesteatoma and non-healing perforation of the eardrum.

4) There was a substantial deflection of the nasal septum to the right side, which could have been contributing to the persistent ear disease.

5) He was placed on an inter-nasal steroid.

6) A CT scan was to be done of the right middle ear space and of the sinuses.

7) It might have been necessary to perform surgery to both the ear and the nose in order to improve the ear.  The CT scans were performed on 2/21/2002.  The radiologist reported:

1)     The temporal bone CT showed a soft tissue density 7 mm in diameter on the right side in the external acoustic meatus, which appeared contiguous with the tympanic membrane.  The radiologist thought the etiology was scarring or cerumen rather than cholesteatoma.

2) The sinus CT showed the following:

a) Rightward deviation of nasal septum.

b) Large (3 cm) polyp in left maxillary sinus.

c) Bilateral mucosal maxillary thickening (moderate on the left and small on the right).

d) Left maxillary infundibulum was not patent.

e) Frontal sinuses and ethmoid air cells patent.

The patient returned to the otolaryngologist’s office on 2/25/2002.  The otolaryngologist listed his diagnoses as hearing loss with mass in right ear, deflected septum, nasal obstruction, turbinate obstruction, and sinus disease.  The otolaryngologist recommended, and the patient consented to, the following surgeries:

1) Right tympanoplasty with tragus perichondrial underlay graft.

2) Septoplasty.

3) Bilateral endoscopic maxillary antrostomies with removal of disease.

4) Bilateral endoscopic anterior and posterior ethmoid resections.

5) Bilateral endoscopic middle turbinate resections.

On 3/21/2002, the otolaryngologist performed the recommended surgeries on the patient.  In performing the bilateral endoscopic anterior and posterior ethmoid resections and the bilateral endoscopic middle turbinate resections, the otolaryngologist did not recommend more conservative treatment that may have been indicated the patient’s history, clinical examination, and CT scans.  While the otolaryngologist was performing the sinus surgical procedures, the otolaryngologist damaged the patient’s cribriform plate and perforated the dura which resulted in an opening between the sinuses and the patient’s brain.  The otolaryngologist was unaware that this occurred.

The otolaryngologist provided post-operative follow-up care to the patient on 4/12/2002, 7/1/2002, 7/17/2002, 8/2/2002, 8/16/2002, 8/30/2002, 9/16/2002, 9/25/2002, 10/4/2002 and 10/23/2002.  During this post-operative period, the patient was experiencing clear drainage from his right nostril.  The patient complained about the drainage to family and friends and also reported it to otolaryngologist during post-operative visits.

The otolaryngologist had listed “cerebrospinal fluid perforation” as a risk of surgery and should have suspected that the fluid draining from the patient’s nose might be cerebral fluid from a defect created by the surgery.  Among other things, the otolaryngologist failed to test the fluid to determine what it was and failed to perform any diagnostic procedures relating to the fluid.

On 10/29/2002, the patient was at home when he became ill, lost consciousness, and was transported by ambulance to the hospital.  He was unresponsive upon arrival at the hospital, never regained consciousness, and died on 10/30/2002.  The final diagnosis was pneumococcal meningitis.  It is more likely than not that the defect in the dura caused during the surgery performed by the otolaryngologist was a cause of the patient’s death.

The otolaryngologist voluntarily participated in an individualized physician assessment performed by evaluators.  The evaluators concluded that the otolaryngologist’s judgment, knowledge, and abilities were adequate for the routine practice of otolaryngology in his community.  The Board ordered that the otolaryngologist pay the costs of the proceeding and be reprimanded.

State: Wisconsin

Date: November 2006

Specialty: Otolaryngology

Symptom: Hearing Problems, Wound Drainage

Diagnosis: Post-operative/Operative Complication, Ear, Nose, or Throat Disease, Meningitis/Encephalitis

Medical Error: Procedural error, Failure to order appropriate diagnostic test, Improper treatment

Significant Outcome: Death

Case Rating: 5

Link to Original Case File: Download PDF

A 20-year-old male was brought to the emergency department on 11/10/2002.  He complained of chills, headache, weakness, and fever of several hours duration, and cold symptoms, fatigue, and sore throat of several days duration.  At 11:50 a.m., his blood pressure was recorded at 134/57, heart rate at 109, respirations at 20, and temperature at 101.3.  Blood analysis of a sample drawn at 12:38 p.m. showed a white count of 5,700, 56% bands, 12% lymphocytes.  The manual analysis of the patient’s blood showed 30% neutrophils.

The ED physician examined the patient at 12:15 p.m. and had a throat culture and urinanlysis sample collected.  A rapid Strep test at approximately 12:30 p.m. was negative.  The ED physician’s record of the examination states that the patient denied neck pain, but that the patient said his neck was a little bit stiff.  The ED physician’s record of the examination states that the patient “does not really have any throat pain” although the patient said he could feel some swollen glands.  The ED physician’s physical examination found the patient’s neck to be “supple and non-tender.”

At 12:55 p.m., the patient was given 30 mg of Toradol for headache pain and the patient reported his headache was almost gone at 2:00 p.m.  At 1:00 p.m., the patient had a blood pressure of 115/50.  At 1:30 p.m., one liter of Lactated Ringers solution was administered to the patient as a flush; at 2:10 p.m., the nurse’s notes state that the flush was complete, and that the patient’s color was “a little more pink.”  His systolic blood pressure was recorded as 111, with no diastolic pressure recorded, heart rate at 110, and temperature at 102.2.

The ED physician suggested a spinal tap to the patient.  The parties disagree on the purpose for the tap.  The ED physician asserts that he sought the tap to evaluate the possibility of viral meningitis.  The complaint suggests the ED physician sought the tap on the possibility of bacterial meningitis.  The ED physician did not prescribe any antibiotics to the patient on the afternoon of 11/10/2002.

The patient was reluctant to consent to the spinal tap. The patient called his mother, who spoke with the ED physician.  The patient’s mother came to the hospital to discuss the situation with the patient and the ED physician.  The ED physician and the patient’s mother discussed a spinal tap.  The ED physician admitted the patient to the hospital, for observation and follow-up care of fever, headache, abdominal pain, and vomiting.

The initial nurse’s note for the patient at 2:50 p.m. records him saying “I’ve never felt this bad” and that his headache “is not so bad now” and describes the patient as very pale.  The nursing notes show the patient was feeling nauseous.  The patient told the nurse that he had stayed up late the previous night and woke up with the symptoms he was then experiencing.  The nursing notes indicate that the patient was oriented to place.

After discussion with the patient and his mother, the ED physician performed a lumbar puncture.  The puncture was performed at about 3:45 to 4:00 p.m.  The spinal fluid obtained was clear and colorless to the eye.  The cerebral spinal fluid was reported to contain one white blood cell and one red blood cell, the glucose was 64 mg/dl, the protein was 17 mg/dl and on gram stain analysis no organisms were seen.

At approximately 3:00 p.m., the nurse’s graphic record for the patient indicates a pulse of 104, respirations at 16, and blood pressure at 126/65.  At 4:00 p.m., the nurse’s note states “very pale; weak voice, very soft; lethargic” and records a temperature of 102.3˚ F.  The nurse’s graphic record indicates a pulse of 119, respirations at 16, blood pressure falling to 105/64.

The ED Physician was performing a spinal tap on the patient at this time and was able to observe the patient’s condition.

The ED Physician’s assessment of the Patient’s condition was that he did not have bacterial meningitis because the spinal fluid was clear and colorless. The ED Physician did not order antibiotics at the time of the lumbar puncture.

At 4:15 p.m., the patient was given 650 mg of Tylenol, and the nurse recorded that the initial laboratory result was negative for meningitis.  At approximately 6:30 p.m., the ED Physician assured the patient’s parents that the patient was comfortable, and needed fluids, but did not need to be transferred to another hospital.  The nurse’s notes for that time indicate that the patient had a temperature of 103.2, and that cold packs were placed at both axilla and on the forehead.  2 mg of morphine sulphate was administered for comfort at 7:00 p.m.

At approximately 8:30 p.m., the patient vomited, and the nurse noted that his color was still very pale, but that his lips now had a pink tinge.  The nurse’s graphic record for the period shows that the patient had a pulse of 109, respirations of 16, and blood pressures of 75/30, and 96/39 on another measurement about the same time.

At 10:10 p.m., the patient was found to have “wine stain” blotches over his entire body.  He was moved to an isolation room, and the ED Physician called an infectious disease consultant because the ED Physician suspected meningococcal disease.  At the suggestion of the infectious disease consultant and after consultation of the Sanford Guide, the ED Physician ordered the administration of Penicillin G, but none could be located in the hospital at the time. Instead, the ED Physician administered Ceftriaxone, 2 grams, IV, at 11:00 p.m.

The patient was noted to have a blood pressure of 86/56; normal saline was infused as a push to improve the blood pressure.  At 11:30 p.m., the patient was noted to be hypoxic.  The ED Physician ordered oxygen by nasal cannula at 2 liters/minute; the patient’s oxygen saturation was measured at 82% with the oxygen, and his blood pressure was measured at

113/73.  The ED Physician called for helicopter transport to another hospital.

At 11:45 p.m., the oxygen was increased to 3 liters/minute; the patient’s oxygen saturation increased to 84%, and his blood pressure was measured at 102/71.  The patient complained of “pain all over.”  At 11:50, the oxygen was increased to 5 liters/minute; the patient’s oxygen saturation decreased to 76%, and his blood pressure was measured at 110/72.

At 11:40 p.m., the patient was given 2 mg of morphine sulphate, IV.  At 12:10 a.m. on 11/11/2002, the patient began to repeatedly clear his throat.  The ED Physician examined him, and saw “significant hemorrhaging occurring back by the tonsils and posterior pharyngeal area.” The ED Physician called for anesthesia assistance for intubation to protect the patient’s airway.

At or about 12:30 a.m., the patient began to cough and stated that his chest “feels like it is filling up.”  On auscultation, the patient’s lungs were congested throughout.  At 12:30 a.m., the patient began to cough up frothy pink fluid.

At 12:45 a.m., the patient lay down, became “less responsive” and the ED Physician began to suction the patient’s airway and attempted intubation.  At 12:50 a.m., a Code Blue was initiated.  The patient was intubated by a CRNA, and suctioned for large amounts of red frothy fluid.  Resuscitation efforts continued until the ED Physician declared the patient dead at 1:06 a.m.

The complaint against the ED physician alleged that the ED Physician’s conduct was below the minimum standard of competence given failure to administer antibiotics to treat suspected bacterial meningitis at or before the time of hospitalization in that such treatment would have been the appropriate treatment for the disease the patient actually had, meningococcemia.  It was alleged the patient presented with symptoms for which the differential diagnosis should have included viral meningitis, sepsis, and bacterial meningitis.

After the investigation, the Board found there was no probable cause to believe the ED physician was guilty of unprofessional conduct or negligence in treatment and ordered that any disciplinary action against the ED physician be dismissed.  The validity that a suspicion of viral meningitis mandated an equal suspicion of bacterial meningitis was disputed.  The ED Physician testified the lack of classical symptoms in the patient’s presenting symptoms indicated bacterial meningitis did not need to be in the differential diagnosis: no stiff neck, no altered mental status, and no focal problems.  It was also not reasonably certain that the amounts of antibiotics that would have been administered for the treatment of suspected bacterial meningitis between 2:30 p.m. and 4:00 p.m. would have had any beneficial effect to the patient.

State: Wisconsin

Date: August 2005

Specialty: Emergency Medicine

Symptom: Nausea Or Vomiting, Fever, Headache

Diagnosis: Meningitis/Encephalitis

Medical Error: False negative

Significant Outcome: Death

Case Rating: 4

Link to Original Case File: Download PDF